Episode 12 of “The THCB Gang” will be live-streamed on Friday, June 5th from 1PM PT to 4PM ET. You can watch it below or on our YouTube Channel.
Tomorrow, Editor-in-Chief, Zoya Khan (@zoyak1594), will be running the show. She will be speaking to economist Jane Sarasohn-Kahn (@healthythinker), executive & mentor Andre Blackman (@mindofandre), writer Kim Bellard (@kimbbellard), MD-turned entrepreneur Jean-Luc Neptune (@jeanlucneptune), and patient advocate Grace Cordovano (@GraceCordovano). The conversation will focus on the issues surrounding disparities in health care as well as updates around the pandemic.
If you’d rather listen, the “audio only” version it is preserved as a weekly podcast available on our iTunes & Spotify channels a day or so after the episode — Matthew Holt
Episode 11 of “The THCB Gang” was live-streamed on Thursday, May 27th and you can see it again below
Joining me were three regulars, patient safety expert Michael Millenson (MLMillenson), writer Kim Bellard (@kimbbellard), health futurist Ian Morrison (@seccurve), and two new guests: digital health investment banker Steven Wardell (@StevenWardell) and MD turned physician leadership coach Maggi Cary (@MargaretCaryMD)! The conversation was heavy on telemedicine and value based care, and their impact on the stock-market, the economy and the health care system–all in a week when we went over 100,000 deaths from COVID-19.
If you’d rather listen, the “audio only” version is preserved as a weekly podcast available on our iTunes & Spotify channels — Matthew Holt
Matthew Holt talks to David Smith who is working on the Medicaid Transformation Project at Avia, which is looking at how hospitals & health plans can improve health outcomes and in turn, lose less money on Medicaid programs. David talks about the tremendous amount of capital being poured into Medicaid, and how the problem is only getting worse. So the focus of the project is trying to reduce healthcare delivery organizations’ spend on these services. At Avia, they are trying to take the best of model science and the best of digital capabilities to help create more efficient care models for their clients as well as reduce costs.
Zoya Khan is the Editor-in-Chief of THCB and a Strategy Manager at SMACK.health
Caution: This post is not a prediction. It’s just a tutorial about the concept of herd immunity, with an eye to why it’s probably not an approach the US wants to take in solving the complex problems we’ve gotten ourselves into with COVID-19.
Click this graphic to go see a six second animation of these images, created in 2017 by Reddit user TheOtherEdmund. You many need to watch a few times. Get a feel for the differences in what happens in the different blocks, and come back to discuss:
This weekend I’ve labored to understand this concept, which first came to my ears regarding coronavirus in March, when British prime minister Boris Johnson proposed it as a possible approach for Britain to take: let the virus take its course, and they’d end up with “herd immunity,” and that would be the end of that.
In my unsophisticated knowledge “herd immunity” meant “you let the weak cows die, and the rest of the herd will be fine.” And in fact in April a Tennessee protestor held up a sign saying “Sacrifice the Weak – Reopen TN.” (It’s not clear whether the sign was mocking or real (Snopes), but it illustrates the point.)
Everyone has an opinion on whether and when we should open
the country. Never in the history of America have we had so many “correct”
theories and experts to pontificate on a new pandemic. But somehow, few seem to
recall history or attempt to learn from it.
Over a century ago, almost 100 million people out of a world population of 1.8 billion lost their lives to the so-called “Spanish Flu”. At 8.5 million casualties, the death toll from World War I pales in comparison. In the US alone, we lost over 675,000 people in one year to this pandemic. In fact, we lost more people to the 1918 flu than to World War I, World War II, the Korean War, and the Vietnam War combined. It was estimated that 5-10% of young adults had died. Nothing has ever come close in devastating the world’s population.
In early 1918, Dr. Miner from Haskell County in Kansas encountered several patients with a severe form of the flu that faded away by March 1918. He was concerned enough to report his observations to the US public health services, who published his concerns but then ignored the issue; there were more pressing problems facing the world, namely World War I. But in Camp Funston, a military complex, soldiers were faced with such cold weather and inadequate clothing that 7,000 of them suffered from the flu and nearly 100 died. Still, these warning signs didn’t seem alarming enough to prevent 1.5 million soldiers from crossing the ocean and going to war in Europe.
A number of politically tinged narratives have
divided physicians during the pandemic. It would be unfortunate if politics
obscured the major problem brought into stark relief by the pandemic: a system
that marginalizes physicians and strips them of agency.
In practices big and small, hospital-employed
or private practice, nursing homes or hospitals, there are serious issues
raising their heads for doctors and their patients.
No masks for you
When I walked into my office Thursday, March 12th, I assembled the office staff for the first time to talk about COVID. The prior weekend had been awash with scenes of mayhem in Italy, and I had come away with the dawning realization that my wishful thinking on the virus from Wuhan skipping us was dead wrong. The US focus had been on travel from China and other Far East hotspots. There was no such limitation on travel from Europe. The virus had clearly seeded Italy and possibly other parts of Europe heavily, and now the US was faced with the very real possibility that there was significant community spread that had occurred from travelers from Europe and Italy over the last month. I had assumed that seeing no cases in our hospitals and ICUs by early March meant the virus had been contained in China. That was clearly not the case.
Our testing apparatus had also largely been limited in the US to symptomatic patients who had been to high-risk countries. If Europe was seeded, this meant we had not been screening nearly enough people. When I heard the first few cases pop up in my county, it was clear the jig was up. It was pandemic panic mode time. There was a chance that there were thousands of cases in the community we didn’t know about and that we were weeks away from the die-off happening in hospitals in China and Italy. So what I told the staff the morning of March 12th was that we needed to start acting now as if there was significant spread of COVID in the community. This meant canceling clinic visits for all but urgent patients, wearing masks, trying to buy masks, attention to hand hygiene, cleaning rooms between patients, screening everyone for flu-like symptoms before coming to the office, and moving to a skeleton staff in the office. I left the office that day wearing a mask as I headed to the ER.
There are so many
stories about the coronavirus pandemic — some inspiring, some tragic, and
all-too-many frustrating. In the world’s supposedly most advanced
economy, we’ve struggled to produce enough ventilators, tests, even swabs, for
I can’t stop thinking
about infrastructure, especially unemployment systems.
We’d never purposely shut down our economy; no nation had. Each state is trying to figure out the best course between limiting exposure to COVID-19 and keeping food on people’s tables. Those workers deemed “essential” still show up for work, others may be able to work from home, but many have suddenly become unemployed.
The U.S. is seeing
unemployment levels not seen since the Great Depression, and occuring in a matter
of a couple months, not several years. As of this writing, there
are over 22 million unemployed; no one believes that is a complete count (not
everyone qualifies for unemployment), and few believe that will be the peak.
systems could not manage the flood of applications.
I am writing this blog post (the first after nearly two years!) in lockdown mode because of the rapidly spreading SARSCoV2 virus, the causative agent of the COVID19 disease (a poor choice of a name, since the disease itself is really SARS on steroids).
One interesting feature of this disease is that a large number of patients will manifest minimal or no symptoms (“asymptomatic” infections), a state which must clearly be distinguished from the presymptomatic phase of the infection. In the latter, many patients who will eventually go on to develop the more serious forms of the disease have minimal symptoms. This is contrast to asymptomatic patients who will never develop anything more bothersome than mild symptoms (“sniffles”), for which they will never seek medical attention. Ever since the early phases of the COVID19 pandemic, a prominent narrative postulated that asymptomatic infections are much more common than symptomatic ones. Therefore, calculations such as the Case Fatality Rate (CFR = deaths over all symptomatic cases) mislead about the Infection Fatality Rate (IFR = deaths over all cases). Subthreads of this narrative go on to postulate that the lockdowns which have been implemented widely around the world are overkill because COVID19 is no more lethal than the flu, when lethality is calculated over ALL infections.
Whereas the politicization of the lockdown argument is of no interest to the author of this blog (after all the virus does not care whether its victim is rich or poor, white or non-white, Westerner or Asian), estimating the prevalence of individuals who were exposed to the virus but never developed symptoms is important for public health, epidemiological and medical care reasons. Since these patients do not seek medical evaluation, they will not detected by acute care tests (viral loads in PCR based assays). However such patients, may be detected after the fact by looking for evidence of past infection, in the form of circulating antibodies in the patients’ serum. I was thus very excited to read about the release of a preprint describing a seroprevalence study in Santa Clara County, California. This preprint described the results of a cross-sectional examination of the residents in the county in Santa Clara, with a lateral flow immunoassay (similar to a home pregnancy kit) for the presence of antibodies against the SARSCoV2 virus. The presence of antibodies signifies that the patient was not only exposed at some point to the virus, but this exposure led to an actual infection to which the immune system responded by forming antibodies. These resulting antibodies persist for far longer than the actual infection and thus provide an indirect record of who was infected. More importantly, such antibodies may be the only way to detect asymptomatic infections, because these patients will not manifest any symptoms that will make them seek medical attention, when they were actively infected. Hence, the premise of the Santa Clara study is a solid one and in fact we need many more of these studies. But did the study actually deliver? Let’s take a deep dive into the preprint.
If you are a soccer fan, watching the FIFA World Cup is a
ritual that you don’t ever violate. Brazilians, arguably more than any other
fans in the world, live and breathe soccer—and they are always expected to be a
legitimate contender to win it all. Their expectations are magnified when they are
the host country, which was the case in 2014. Not only did the Germans destroy
Brazilian World Cup dreams, but less than a year after a humiliating loss
on their turf, Brazilians began dealing with another devastating blow: a viral
epidemic. Zika left the country scrambling to understand how to manage the
devastation caused by the virus and grappling with conspiracies theories of
whether the virus was linked to the tourism brought by hosting the FIFA World
How did I become so interested in what happened in Brazil five
years ago? Well, social distancing and being mostly at home in the era of
COVID-19 seems to energize reflection. Watching politicians on TV networks blaming
each other and struggling to appear more knowledgeable than scientists makes me
marvel at the hubris. My mind took me back to several prior epidemics that we
encountered from Swine Flu to Ebola, and I couldn’t help but think about the lessons
lost. What did we miss in these previous crises to land us in this current
state where Zoom is your best friend and you are more interested in commenting
on tweets than doing a peer-review? One cannot help but wonder what is so
different about this coronavirus that it has paralyzed the globe.
I decided to take a deep dive into the Zika epidemic in a
hopeful effort to better understand the present public health crisis. I started
by reading Zika: The Emerging Epidemic, by Donald G. McNeil Jr, who also
covers global epidemics for the New York Times. The book is a
fascinating read and offers illuminating parallels to the current failings we
are seeing with national and global health protection agencies during the COVID-19
As a psychiatrist, my role in COVID-19 has included that of a therapist for my colleagues. I helped start Physician Support Line, a peer-to-peer hotline for physicians staffed by more than 500 volunteer psychiatrists. Through the hotline and social media, physicians are revealing their emotional fatigue. One doctor shared her sense of powerlessness when she couldn’t provide comfort but instead had to watch her young patient with COVID-19 die alone from behind a glass window. Another shared his sorrow after his 72-year-old patient died by suicide. She was socially isolated and didn’t want to be a burden on anyone if she contracted COVID-19. An internist felt deep distress and alarm that her hospital was quickly running out of ventilators and had 12 codes in 24 hours.
Through a brief survey I
conducted across the U.S., 269 physicians reported moderate to severe symptoms
of anxiety (53%), depression (43%), and insomnia (16%). About 46% wanted to see
or would consider seeing a mental health clinician for severe anxiety (30%),
not feeling like themselves (27%), or being unhappy (21%). These are all similar statistics to
the front line health care workers in Wuhan.